Practicode VI (501-600)
Terms in this set (100)
MEDICAL RECORD
SEX: MALE Age: 27DATE OF OPERATION: 01/1/20XXPREOPERATIVE DIAGNOSIS:
LEFT BOTH BONE FOREARM OPEN FRACTURE DISPLACED COMMINUTED
DUE TO GUNSHOT WOUND ULNA AND RADIUS SHAFTS TYPE IIIPROCEDURES:
LEFT FOREARM INTRAMEDULLARY NAILING WITH ACUMED INTRAMEDULLARY
NAILS, REPEAT IRRIGATION OF GUNSHOT WOUNDSPOSTOPERATIVE DIAGNOSIS:
LEFT BOTH BONE FOREARM OPEN FRACTURE DISPLACED COMMINUTED DUE
TO GUNSHOT WOUND ULNA AND RADIUS SHAFTS TYPE IIISURGEON:
Stephanie Andrews MDANESTHESIA: GENERAL, ENDOTRACHEAL
TUBE.ESTIMATE BLOOD LOSS: 10 CC.TOURNIQUET TIME: 60
MINUTES.ANTIBIOTICS: ANCEF 1
GM.COMPLICATIONS: NONE.INDICATIONS: The patient is a male who sustained
CaseID: OPD6930
gunshot wounds to the abdomen and the left forearm and he was stabilized by
Primary Diagnosis: S52.252C, S52.352C
general surgery (ulna and radius shaft fractured) Options, risks and benefits were
CPT: 25575-LT
discussed with the patient and his father and they agreed with the internal fixation. I
recommend an intramedullary rod due to the comminution and the probability
of poor fixation with plating on the radius.PROCEDURE: The patient was brought to
the operating room and anesthesia was induced via endotracheal tube. The left
upper extremity was prepped and draped in sterile fashion. It was elevated, and the
tourniquet was inflated to 250.A longitudinal incision was made over the tip of the
olecranon and taken down to the triceps which was split longitudinally over the
tip of the olecranon. The medullary canal was opened with the awl and a
reamer was placed on the medullary canal across the fracture site. The length was
measured and Acumed ulnar nail was then placed and the proximal interlock
was placed from the radial to medial direction using the guide and stab incision.
This obtained good purchase.Attention was then turned to the radius and under C-
arm control an incision was made over the distal radius over the fou
, MEDICAL RECORD
AGE: 41SEX: MALEDate of Service: 1/1/20XXService Department: Orthopedic Group
GeneralOPERATIVE NOTENAME OF PROCEDURE: Left knee examination under
anesthesia, arthroscopy, and anterior cruciate ligament reconstruction, of an old
disruption of the ACL with chronic instability.SURGEON:ANESTHESIA: General with
blocks.DESCRIPTION OF PROCEDURE: With the patient in the supine position under
endotracheal intubation with general anesthesia, the left knee was examined. There
was a moderate amount of clear yellow effusion. There were intact collateral
ligaments. There were positive Lachman, pivot shift, and drawer signs and an intact
PCL.The knee was prepped and draped free in the usual manner. Portals were
CaseID: OPD6936 established inferolaterally and inferomedially.The medial component had normal
Primary Diagnosis: S83.512A cartilage in both articular surfaces, and the medial meniscus was intact to
Secondary Diagnosis: M25.362, M25.462 visualization and probing.The notch had large fragments of the anterior cruciate
CPT: 29888-LT ligament caught in the notch. There was a midsubstance tear, with some tissue
remaining on the femoral side and tibial side.The lateral compartment had normal
cartilage in both articular surfaces. Lateral meniscus, popliteal tendon intact to
visualization and probing.The patellofemoral joint had normal alignment and normal
cartilage on both surfaces. Suprapatellar pouch and both gutters were clear of
any loose bodies.In the notch, we paid our attention to the stump of the anterior
cruciate ligament, which was removed down to bone to expose the tibial spines. We
removed soft tissue from the lateral side of the notch. We performed notchplasty
using a curved gouge and power instruments back to the over the top position.With
the knee at 90 degrees, we used an over-the-top guide and made a proximal mid
and tibial area skin incision. We placed a guidewire across the tibia to enter the j
MEDICAL RECORD
Age: 58Sex: FDate of Service: 1/1/20XXService Department: Orthopedic Group
GeneralProvider: Dr.OPERATIVE NOTE:PREOPERATIVE DIAGNOSIS: Chronic lateral
epicondylitis in the left elbow.POSTOPERATIVE DIAGNOSIS: Same.NAME OF
PROCEDURE: Lateral tennis elbow release, left elbow.SURGEON:DESCRIPTION
OF PROCEDURE: The female patient was taken to the operating room and after
satisfactory regional anesthesia, the left elbow was thoroughly scrubbed,
prepped, and draped in the usual manner. A longitudinal incision was made
CaseID: OPD6939
overlying the later aspect of the elbow. The incision was deepened through the
Primary Diagnosis: M77.12
subcutaneous tissue through the epicondyle. The epicondyle area was exposed by
CPT: 24359-LT
dissecting through the rather extensive subcutaneous fatty tissue. The interval
between the common extensor and the ECRB was identified. The common
extensor was reflected and the underlying ECRB had an area of necrosis. This was
excised. The remaining tendon was sutured together. The anterior aspect of the
lateral epicondyle was roughened with a rongeur. The wound was then irrigated,
and the subcutaneous tissue was closed with 2-0 Vicryl and skin with wire staples. A
sterile dressing was applied.The patient was taken to the recovery room in
satisfactory condition with a splint in place.Electronically signed by 1/1/20XX
, MEDICAL RECORD
Age: 87 Sex: FEMALEDate of Service: 01/01/20XXService Department: Orthopedic
Group General Clinic
DIAGNOSIS: Right hip joint primary osteoarthritis.PROCEDURE: Right hip cortisone
injection.SURGEON: Dr. MDDESCRIPTION OF PROCEDURE: The patient was placed
on fluoroscopy table in a supine position. The right hip was identified under
CaseID: OPD6950
fluoroscopy. The skin was prepped with Betadine, skin anesthetized with 1%
Primary Diagnosis: M16.11
lidocaine. Under fluoroscopy guidance, a 22-gauge needle was guided into the
CPT: 20610-RT, 77002
right hip capsule using anterolateral approach. Confirmation made by injection
of a small amount of contrast. Once this was confirmed, injection of bupivacaine
and Kenalog was placed in the hip capsule. The patient tolerated the procedure
well without complications, leaving the department in improved, stable condition.
We will see her back to follow up in the office for recheck and reevaluation.
Reinjections as needed.Electronically signed by: MD 1/1/20XX
MEDICAL RECORD
OPERATIVE REPORTSEX: MALE AGE: 35DATE OF OPERATION:
1/1/20XXPREOPERATIVE DIAGNOSIS: LEFT MIDSHAFT CLAVICLE FRACTURE
DISPLACED.PROCEDURES: LEFT CLAVICLE ORIF WITH
FLUOROSCOPY.POSTOPERATIVE DIAGNOSIS: LEFT MIDSHAFT CLAVICLE
FRACTURE DISPLACED.FLUOROSCOPY (Included in Procedure)SURGEON: Dr.
MDANESTHESIA: GENERAL, ENDOTRACHEAL TUBE.ESTIMATE BLOOD LOSS: 100
CC.ANTIBIOTICS: CLINDAMYCIN 900 MG.COMPLICATIONS: NONE.INDICATIONS:
The patient is a male who had a motorcycle accident with the left clavicle
fractured which was widely displaced with the proximal fragment appearing to be
impaled into the trapezius. Options, risks and benefits were discussed with the
CaseID: OPD6958 patient. He agreed with the open reduction internal fixation.PROCEDURE: The
Primary Diagnosis: S42.022A patient was brought to the operating room and anesthesia was induced via
CPT: 23515-LT endotracheal tube. The left upper extremity and chest were then prepped and
draped in sterile fashion. An incision was marked over the fractured clavicle and
infiltrated with lidocaine 1% with epinephrine. It was then established, taken down
through the subcutaneous tissue to the pectoral trapezial fascia which was incised
longitudinally along the clavicle and the inferior surface of the clavicle was
dissected to protect the lung.The fracture fragments were subperiosteally
dissected, irrigated out and curetted. Anatomic reduction was then performed
and held with K-wire. An Acumed clavicle plate was then placed along the
superior surface of the clavicle. A 2.8 drill was used to create drill holes and the
fracture was compressed followed by locking screws. C-arm images confirmed
anatomic reduction and good position of the hardware. The shoulder was put
through a full range of motion.The wound was then irrigated out. Trapezial
pectoral fascia was closed with running and interrupted 2-0 Vicryl. The
subcutaneous tissu
, MEDICAL RECORD
OPERATIVE REPORTAGE: 44 Y SEX: FEMALEDATE OF OPERATION:
01/01/20XXPREOPERATIVE DIAGNOSIS: RIGHT UPPER EXTREMITYPROCEDURES:
RIGHT UPPER EXTREMITY BRACHIAL AND AXILLARY THROMBECTOMY.
POSTOPERATIVE DIAGNOSIS: RIGHT UPPER EXTREMITY THROMBOSIS
SURGEON: M.D.
ANESTHESIA: GENERAL.
ESTIMATED BLOOD LOSS: MINIMAL
COMPLICATIONS: NONE.
INDICATIONS: A female patient was admitted to the hospital with clinical
presentation of acute right upper extremity ischemia. Angiography was done which
demonstrated presence of clots in the right axillary artery. At this point, after
consultation with the patient and patient's family, a decision was made to proceed
CaseID: OPD6971
with a surgical thrombectomy from the right axillary brachial arteries.
Primary Diagnosis: I74.2
PROCEDURE: The patient was brought to the operating room and placed on the
CPT: 34101-RT
OR table in the supine position. General anesthesia was administered. The patient's
right upper extremity were prepped and draped for sterile procedure.Incision was
done in the proximal right forearm in longitudinal direction above the projection
of the brachial artery. The brachial artery was quickly identified and appeared
significantly inflamed with the vein tightly adherent to that. A very difficult
dissection was followed in this area and finally brachial artery was dissected taking
on the Vessel loop as well as radial, ulnar and interosseous arteries.The patient was
systemically heparinized with 5000 units of heparin. After 5 minutes of circulation,
transverse arteriotomy was made above the trifurcation of the brachial artery within
2 cm above the bifurcation of the brachial artery.We could not find the lumen of
the artery, which appeared completely occluded. Finally, we removed
something which appeared to be well- organized clot, however, attempt to
send the embolectomy cath in proximal and distal direction were unsuccessf
MEDICAL RECORD
AGE: 53SEX: MALEDATE OF OPERATION:1/1/20XXPREOPERATIVE DIAGNOSIS: ANAL
CONDYLOMATASPROCEDURES: FULGURATION OF ANAL CONDYLOMATAS -
ANOSCOPYPOSTOPERATIVE DIAGNOSIS: ANAL
CONDYLOMATASSURGEON: MDConscious Sedation: Intraservice Time 20
min.ESTIMATED BLOOD LOSS: MINIMAL.INDICATION: The patient is a 53-year-old
male positive for HIV. The patient came into OR for anal condylomas.PROCEDURE:
CaseID: OPD6982 The patient was brought into the OR at 9 o'clock. The patient was put in prone
Primary Diagnosis: A63.0 position and procedure was done under local anesthesia and conscious
Secondary Diagnosis: Z21 sedation. The patient was put in prone position. The anal area was painted with
CPT: 46612, 99152 Betadine and standard drapes were placed around the area. After giving 16 ccs of
lidocaine IV, the anoscope was inserted in the anus and the electrocauterization
was used to remove the condylomas. The whole process took about 20 minutes. All
condylomatas were removed and the wound sites were cleaned. No active bleeding
and Vaseline gauze was used to cover the wound site.The patient was sent to
the PACU after the procedure. The patient was visited by the resident. The patient
can be discharged home. Tylenol #3 and sitz bath instructions have been given to
the patient and the patient can be follow up in the rectal clinic.Electronically
signed by: MD 1/1/20XX
Terms in this set (100)
MEDICAL RECORD
SEX: MALE Age: 27DATE OF OPERATION: 01/1/20XXPREOPERATIVE DIAGNOSIS:
LEFT BOTH BONE FOREARM OPEN FRACTURE DISPLACED COMMINUTED
DUE TO GUNSHOT WOUND ULNA AND RADIUS SHAFTS TYPE IIIPROCEDURES:
LEFT FOREARM INTRAMEDULLARY NAILING WITH ACUMED INTRAMEDULLARY
NAILS, REPEAT IRRIGATION OF GUNSHOT WOUNDSPOSTOPERATIVE DIAGNOSIS:
LEFT BOTH BONE FOREARM OPEN FRACTURE DISPLACED COMMINUTED DUE
TO GUNSHOT WOUND ULNA AND RADIUS SHAFTS TYPE IIISURGEON:
Stephanie Andrews MDANESTHESIA: GENERAL, ENDOTRACHEAL
TUBE.ESTIMATE BLOOD LOSS: 10 CC.TOURNIQUET TIME: 60
MINUTES.ANTIBIOTICS: ANCEF 1
GM.COMPLICATIONS: NONE.INDICATIONS: The patient is a male who sustained
CaseID: OPD6930
gunshot wounds to the abdomen and the left forearm and he was stabilized by
Primary Diagnosis: S52.252C, S52.352C
general surgery (ulna and radius shaft fractured) Options, risks and benefits were
CPT: 25575-LT
discussed with the patient and his father and they agreed with the internal fixation. I
recommend an intramedullary rod due to the comminution and the probability
of poor fixation with plating on the radius.PROCEDURE: The patient was brought to
the operating room and anesthesia was induced via endotracheal tube. The left
upper extremity was prepped and draped in sterile fashion. It was elevated, and the
tourniquet was inflated to 250.A longitudinal incision was made over the tip of the
olecranon and taken down to the triceps which was split longitudinally over the
tip of the olecranon. The medullary canal was opened with the awl and a
reamer was placed on the medullary canal across the fracture site. The length was
measured and Acumed ulnar nail was then placed and the proximal interlock
was placed from the radial to medial direction using the guide and stab incision.
This obtained good purchase.Attention was then turned to the radius and under C-
arm control an incision was made over the distal radius over the fou
, MEDICAL RECORD
AGE: 41SEX: MALEDate of Service: 1/1/20XXService Department: Orthopedic Group
GeneralOPERATIVE NOTENAME OF PROCEDURE: Left knee examination under
anesthesia, arthroscopy, and anterior cruciate ligament reconstruction, of an old
disruption of the ACL with chronic instability.SURGEON:ANESTHESIA: General with
blocks.DESCRIPTION OF PROCEDURE: With the patient in the supine position under
endotracheal intubation with general anesthesia, the left knee was examined. There
was a moderate amount of clear yellow effusion. There were intact collateral
ligaments. There were positive Lachman, pivot shift, and drawer signs and an intact
PCL.The knee was prepped and draped free in the usual manner. Portals were
CaseID: OPD6936 established inferolaterally and inferomedially.The medial component had normal
Primary Diagnosis: S83.512A cartilage in both articular surfaces, and the medial meniscus was intact to
Secondary Diagnosis: M25.362, M25.462 visualization and probing.The notch had large fragments of the anterior cruciate
CPT: 29888-LT ligament caught in the notch. There was a midsubstance tear, with some tissue
remaining on the femoral side and tibial side.The lateral compartment had normal
cartilage in both articular surfaces. Lateral meniscus, popliteal tendon intact to
visualization and probing.The patellofemoral joint had normal alignment and normal
cartilage on both surfaces. Suprapatellar pouch and both gutters were clear of
any loose bodies.In the notch, we paid our attention to the stump of the anterior
cruciate ligament, which was removed down to bone to expose the tibial spines. We
removed soft tissue from the lateral side of the notch. We performed notchplasty
using a curved gouge and power instruments back to the over the top position.With
the knee at 90 degrees, we used an over-the-top guide and made a proximal mid
and tibial area skin incision. We placed a guidewire across the tibia to enter the j
MEDICAL RECORD
Age: 58Sex: FDate of Service: 1/1/20XXService Department: Orthopedic Group
GeneralProvider: Dr.OPERATIVE NOTE:PREOPERATIVE DIAGNOSIS: Chronic lateral
epicondylitis in the left elbow.POSTOPERATIVE DIAGNOSIS: Same.NAME OF
PROCEDURE: Lateral tennis elbow release, left elbow.SURGEON:DESCRIPTION
OF PROCEDURE: The female patient was taken to the operating room and after
satisfactory regional anesthesia, the left elbow was thoroughly scrubbed,
prepped, and draped in the usual manner. A longitudinal incision was made
CaseID: OPD6939
overlying the later aspect of the elbow. The incision was deepened through the
Primary Diagnosis: M77.12
subcutaneous tissue through the epicondyle. The epicondyle area was exposed by
CPT: 24359-LT
dissecting through the rather extensive subcutaneous fatty tissue. The interval
between the common extensor and the ECRB was identified. The common
extensor was reflected and the underlying ECRB had an area of necrosis. This was
excised. The remaining tendon was sutured together. The anterior aspect of the
lateral epicondyle was roughened with a rongeur. The wound was then irrigated,
and the subcutaneous tissue was closed with 2-0 Vicryl and skin with wire staples. A
sterile dressing was applied.The patient was taken to the recovery room in
satisfactory condition with a splint in place.Electronically signed by 1/1/20XX
, MEDICAL RECORD
Age: 87 Sex: FEMALEDate of Service: 01/01/20XXService Department: Orthopedic
Group General Clinic
DIAGNOSIS: Right hip joint primary osteoarthritis.PROCEDURE: Right hip cortisone
injection.SURGEON: Dr. MDDESCRIPTION OF PROCEDURE: The patient was placed
on fluoroscopy table in a supine position. The right hip was identified under
CaseID: OPD6950
fluoroscopy. The skin was prepped with Betadine, skin anesthetized with 1%
Primary Diagnosis: M16.11
lidocaine. Under fluoroscopy guidance, a 22-gauge needle was guided into the
CPT: 20610-RT, 77002
right hip capsule using anterolateral approach. Confirmation made by injection
of a small amount of contrast. Once this was confirmed, injection of bupivacaine
and Kenalog was placed in the hip capsule. The patient tolerated the procedure
well without complications, leaving the department in improved, stable condition.
We will see her back to follow up in the office for recheck and reevaluation.
Reinjections as needed.Electronically signed by: MD 1/1/20XX
MEDICAL RECORD
OPERATIVE REPORTSEX: MALE AGE: 35DATE OF OPERATION:
1/1/20XXPREOPERATIVE DIAGNOSIS: LEFT MIDSHAFT CLAVICLE FRACTURE
DISPLACED.PROCEDURES: LEFT CLAVICLE ORIF WITH
FLUOROSCOPY.POSTOPERATIVE DIAGNOSIS: LEFT MIDSHAFT CLAVICLE
FRACTURE DISPLACED.FLUOROSCOPY (Included in Procedure)SURGEON: Dr.
MDANESTHESIA: GENERAL, ENDOTRACHEAL TUBE.ESTIMATE BLOOD LOSS: 100
CC.ANTIBIOTICS: CLINDAMYCIN 900 MG.COMPLICATIONS: NONE.INDICATIONS:
The patient is a male who had a motorcycle accident with the left clavicle
fractured which was widely displaced with the proximal fragment appearing to be
impaled into the trapezius. Options, risks and benefits were discussed with the
CaseID: OPD6958 patient. He agreed with the open reduction internal fixation.PROCEDURE: The
Primary Diagnosis: S42.022A patient was brought to the operating room and anesthesia was induced via
CPT: 23515-LT endotracheal tube. The left upper extremity and chest were then prepped and
draped in sterile fashion. An incision was marked over the fractured clavicle and
infiltrated with lidocaine 1% with epinephrine. It was then established, taken down
through the subcutaneous tissue to the pectoral trapezial fascia which was incised
longitudinally along the clavicle and the inferior surface of the clavicle was
dissected to protect the lung.The fracture fragments were subperiosteally
dissected, irrigated out and curetted. Anatomic reduction was then performed
and held with K-wire. An Acumed clavicle plate was then placed along the
superior surface of the clavicle. A 2.8 drill was used to create drill holes and the
fracture was compressed followed by locking screws. C-arm images confirmed
anatomic reduction and good position of the hardware. The shoulder was put
through a full range of motion.The wound was then irrigated out. Trapezial
pectoral fascia was closed with running and interrupted 2-0 Vicryl. The
subcutaneous tissu
, MEDICAL RECORD
OPERATIVE REPORTAGE: 44 Y SEX: FEMALEDATE OF OPERATION:
01/01/20XXPREOPERATIVE DIAGNOSIS: RIGHT UPPER EXTREMITYPROCEDURES:
RIGHT UPPER EXTREMITY BRACHIAL AND AXILLARY THROMBECTOMY.
POSTOPERATIVE DIAGNOSIS: RIGHT UPPER EXTREMITY THROMBOSIS
SURGEON: M.D.
ANESTHESIA: GENERAL.
ESTIMATED BLOOD LOSS: MINIMAL
COMPLICATIONS: NONE.
INDICATIONS: A female patient was admitted to the hospital with clinical
presentation of acute right upper extremity ischemia. Angiography was done which
demonstrated presence of clots in the right axillary artery. At this point, after
consultation with the patient and patient's family, a decision was made to proceed
CaseID: OPD6971
with a surgical thrombectomy from the right axillary brachial arteries.
Primary Diagnosis: I74.2
PROCEDURE: The patient was brought to the operating room and placed on the
CPT: 34101-RT
OR table in the supine position. General anesthesia was administered. The patient's
right upper extremity were prepped and draped for sterile procedure.Incision was
done in the proximal right forearm in longitudinal direction above the projection
of the brachial artery. The brachial artery was quickly identified and appeared
significantly inflamed with the vein tightly adherent to that. A very difficult
dissection was followed in this area and finally brachial artery was dissected taking
on the Vessel loop as well as radial, ulnar and interosseous arteries.The patient was
systemically heparinized with 5000 units of heparin. After 5 minutes of circulation,
transverse arteriotomy was made above the trifurcation of the brachial artery within
2 cm above the bifurcation of the brachial artery.We could not find the lumen of
the artery, which appeared completely occluded. Finally, we removed
something which appeared to be well- organized clot, however, attempt to
send the embolectomy cath in proximal and distal direction were unsuccessf
MEDICAL RECORD
AGE: 53SEX: MALEDATE OF OPERATION:1/1/20XXPREOPERATIVE DIAGNOSIS: ANAL
CONDYLOMATASPROCEDURES: FULGURATION OF ANAL CONDYLOMATAS -
ANOSCOPYPOSTOPERATIVE DIAGNOSIS: ANAL
CONDYLOMATASSURGEON: MDConscious Sedation: Intraservice Time 20
min.ESTIMATED BLOOD LOSS: MINIMAL.INDICATION: The patient is a 53-year-old
male positive for HIV. The patient came into OR for anal condylomas.PROCEDURE:
CaseID: OPD6982 The patient was brought into the OR at 9 o'clock. The patient was put in prone
Primary Diagnosis: A63.0 position and procedure was done under local anesthesia and conscious
Secondary Diagnosis: Z21 sedation. The patient was put in prone position. The anal area was painted with
CPT: 46612, 99152 Betadine and standard drapes were placed around the area. After giving 16 ccs of
lidocaine IV, the anoscope was inserted in the anus and the electrocauterization
was used to remove the condylomas. The whole process took about 20 minutes. All
condylomatas were removed and the wound sites were cleaned. No active bleeding
and Vaseline gauze was used to cover the wound site.The patient was sent to
the PACU after the procedure. The patient was visited by the resident. The patient
can be discharged home. Tylenol #3 and sitz bath instructions have been given to
the patient and the patient can be follow up in the rectal clinic.Electronically
signed by: MD 1/1/20XX
